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The Surgery Scheduling Sheet is a crucial document that assists both medical staff and patients in managing surgical procedures efficiently. It captures essential details such as the patient's name, surgery date, arrival time, and procedure information, including the corresponding CPT codes. Clear contact information, including phone numbers and addresses, is provided to ensure effective communication. It includes sections for recording the diagnosis with ICD9 codes, the surgeon’s information, and any allergies the patient may have. Furthermore, the form outlines necessary pre-surgery testing and indicates where those tests have been completed. Health providers can mark the type of anesthesia to be used and note any additional orders or special instructions. This structured approach ensures that all stakeholders are informed and prepared, contributing to a smoother surgical process.

Surgery Scheduling Sheet Example

SURGERY SCHEDULING SHEET &

PHYSICIANS PRE-ADMISSION TESTING ORDERS

PLEASE FAX TO 866-647-0527, ALONG WITH COPY OF INSURANCE CARD

NAME

 

 

SURGERY DATE

ARRIVAL TIME

SURGERY TIME

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

PROCEDURE & CPT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**CIRCLE ONE**

R

L

 

 

 

 

 

 

 

PHONE (H)

 

 

DIAGNOSIS & ICD9

 

 

 

 

 

 

 

 

 

 

PHONE (W)

 

(C)

 

 

 

 

 

 

 

 

 

 

 

SS#

 

 

SURGEON

 

 

 

 

 

 

 

 

 

 

DOB

 

 

REFERRING PHYSICIAN

 

 

 

 

 

 

 

 

 

 

ALLERGIES

 

 

PCP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANESTHESIA TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

**CIRCLE ONE**

OP

 

23HR OBSERVATION

INPATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST

DONE

WHERE

Anesthesia

 

 

EKG

 

 

CBC

 

 

HEMOCUE

 

 

BASIC METABOLIC

 

 

PANEL

 

 

(BUN, CR, NA, K, CL,

 

 

CO2, Glucose)

 

 

COMPREHENSIVE METABOLIC PANEL (Albumin, Phosphate, AST, Bilirubin – Total, BUN, CA, CR, NA, K, CL, CO2, Glucose, Protein Total)

LIVER PANEL

BUN / Creatinine

TEST

DONE

WHERE

 

 

 

ELECTROLYTE

PANEL

K

BLOOD

PT / PTT

CHEST X-RAY

UR PREG / HCG

CRUTCH

TRAINING

ADDITIONAL ORDERS / SPECIAL INSTRUCTIONS:

_________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________

_________________________________________________________________

_________________________________________________________________________

**PHYSICIAN’S SIGNATURE**

DATE

PATIENT NAME:______________________________________________

SURGERY PROCEDURE:________________________________________

SURGEON:__________________________________________________

DATE OF SURGERY:___________________________________________

TIME OF SURGERY:_____________ ARRIVAL TIME:_________________

PATIENT INFORMATION:

Our professional staff is dedicated to providing the highest quality of individualized care to each of our patients. This patient focused approach is intended to promote long term health and well being that results in a high degree of patient satisfaction.

We want to make your upcoming visit as pleasant and comfortable as possible. To make your surgery a successful experience, please read and follow the information on the enclosed sheet.

DAY OF SURGERY:

OArrive promptly at the scheduled time. This will allow adequate time for all necessary pre-surgery procedures.

OPlease bring your insurance identification cards. If special financial arrangements are necessary, please call the Medical Center prior to arrival.

OBe sure to bring any paperwork your doctor gave you, such as test results and/or films, and a list of all medications you are taking.

OWear comfortable, loose fitting clothing.

OUpon arrival, you will change into a gown and slippers which we will provide. You will be asked to remove contact lenses, dentures and any prosthesis.

PREPARING FOR YOUR SURGERY:

Sometime before your surgery date, a staff member from the Medical Center will call you to confirm your surgery time.

They will also ask you questions regarding current and past medical conditions, allergies and medications you are taking. Please don’t hesitate to ask any questions you may have. Be sure to let the staff know of any special needs.

OYou will be instructed as to what time you are to stop eating and drinking prior to your surgery and what medications you should or should not take.

OFor women, if there is any possibility you are pregnant, please notify your doctor and the Medical Center nurse.

OLeave all valuables at home, including watches, rings, jewelry and wallets.

ONotify your surgeon of any changes in your health such as a cold or fever.

OFor your safety, please arrange for an adult to drive you home after surgery. You will not be allowed to drive yourself home.

MEDICAL CENTER at ELIZABETH PLACE

1 Elizabeth Pl, Dayton, OH 45408-1445

Telephone: 937-223-MCEP

DIRECTIONS and MAP

From South of Dayton

Take I-75 NORTH into Dayton

Take the Edwin C. Moses exit (#51)

Turn RIGHT at the end of the exit ramp onto Edwin C. Moses

Follow Edwin C. Moses just over 1 mile

Turn left onto Albany St (before the Dayton Heart Hospital)

Turn right onto Elizabeth Place

From North of Dayton

Take I-75 SOUTH into Dayton

Stay on I-75 (approximately 14 miles south of I-70)

Take the Albany Street exit

Turn LEFT at the end of the exit ramp onto Albany Street

Turn LEFT onto Cincinnati Street (at a 4-way stop)

Turn RIGHT onto Elizabeth Place

Valet Parking available in front of the West Pavilion (no charge). Enter through main entrance; turn right to go to the elevators. Take the elevator to the second floor; the medical center is to the left.

Form Characteristics

Fact Name Description
Form Purpose The Surgery Scheduling Sheet is essential for organizing surgical appointments and preparing patient data.
Required Information It collects critical patient information such as name, insurance details, surgery date, and special instructions.
Contact Details Fax to 866-647-0527, ensuring timely processing of the surgery schedule.
Anesthesia Choices Patients need to indicate their anesthesia type; options include OP, 23HR Observation, and Inpatient.
Medical Tests Required pre-surgery tests may include EKG, CBC, and various metabolic panels.
Patient Instructions Instructions emphasize the importance of timely arrival and preparedness before surgery.
Legal Compliance This form must adhere to state laws regarding patient information confidentiality, including the Health Insurance Portability and Accountability Act (HIPAA).
Signature Requirement The form must be signed by the physician to validate the surgery schedule and patient consent.

Guidelines on Utilizing Surgery Scheduling Sheet

Once you have collected all necessary information, it is time to proceed with filling out the Surgery Scheduling Sheet. This form ensures that all pertinent details regarding the upcoming surgery are documented and communicated effectively. Accurate completion of this form is crucial for a smooth surgical process, so take your time to provide all required information.

  1. Patient Information: Start by entering the patient’s name at the top of the form.
  2. Surgery Details: Fill out the surgery date, arrival time, and surgery time.
  3. Address: Provide the patient’s address.
  4. Procedure Information: Specify the procedure and its CPT code, ensuring to circle either “R” or “L” as applicable.
  5. Phone Numbers: Include the patient's home, work, and cell phone numbers.
  6. Diagnosis and Codes: Enter the diagnosis and the corresponding ICD9 code.
  7. Surgeon Information: Write down the name of the surgeon performing the procedure and their date of birth.
  8. Referring Physician: Note who referred the patient for this surgery.
  9. Allergies: List any allergies the patient has.
  10. Primary Care Physician (PCP): Include the name of the patient’s primary care physician.
  11. Anesthesia Type: Circle the type of anesthesia as indicated on the form.
  12. Tests Done: Fill in the required tests done, indicating where they were completed, such as EKG, CBC, etc. Include any additional orders or special instructions in the provided space.
  13. Physician’s Signature: Have the physician sign and date the form.
  14. Final Details: Review all the entered information for accuracy before submitting the sheet.

Completing these steps ensures that necessary information is thorough and correctly submitted, contributing to a successful surgical experience for the patient. Once the form is filled out, it should be faxed to the specified number, along with a copy of the insurance card.

What You Should Know About This Form

What is the purpose of the Surgery Scheduling Sheet?

The Surgery Scheduling Sheet is designed to collect important information from patients and their physicians before surgery. It ensures that all necessary details, like the surgery date, physician's information, and medical history, are accurately recorded. This form helps streamline the scheduling process, allowing the medical staff to prepare adequately for each patient's specific needs.

How do I submit the Surgery Scheduling Sheet?

Once you have filled out the Surgery Scheduling Sheet, please fax it to 866-647-0527. Make sure to also include a copy of your insurance card to ensure that your information is complete. This will help facilitate the scheduling process and ensure that everything is in order prior to your surgery date.

What should I bring on the day of surgery?

On the day of your surgery, please arrive promptly at the scheduled time. Remember to bring your insurance identification cards and any paperwork your doctor provided, such as test results or films. Additionally, carry a list of all medications you are currently taking. Comfortable, loose-fitting clothing is recommended, as you will change into a gown and slippers upon arrival.

Can I eat or drink before my surgery?

No, specific instructions regarding eating and drinking will be provided to you prior to your surgery. A staff member from the Medical Center will call you to confirm the time and discuss any preparations needed, including when to stop eating or drinking. It is crucial to follow these instructions to ensure your safety during the procedure.

What if I have special medical needs or concerns?

If you have special medical needs or concerns, it is important to communicate them to the staff during your pre-surgery call. They are there to assist you and can accommodate your needs whenever possible. Do not hesitate to ask questions or discuss any worries you may have about the upcoming surgery.

Why is it important to arrange for someone to drive me home after surgery?

After your surgery, you may be under the effects of anesthesia, which can impair your ability to drive safely. Therefore, it is crucial to arrange for an adult to drive you home. This ensures your safety and well-being after the procedure, as you will not be allowed to drive yourself.

Common mistakes

Filling out the Surgery Scheduling Sheet can be daunting, especially when accuracy is crucial. One common mistake is leaving out important details such as the surgery date and time. These fields are vital for ensuring that everything proceeds smoothly on the day of the procedure. Incomplete information can lead to scheduling conflicts and confusion.

Another frequent error is failing to specify insurance details. A clear record of insurance coverage helps streamline the administrative process and can prevent unexpected charges. Patients should ensure they send a copy of their insurance card along with the form. Missing this documentation might delay the surgery.

Inaccurate contact information can also be problematic. People sometimes provide outdated phone numbers, making it difficult for the medical staff to reach them for pre-surgery confirmation or in case of any last-minute changes. It is essential to double-check that the provided phone numbers are correct and active.

People often neglect to indicate allergies on the form. This omission can have serious implications for patient safety. Anesthesia and other medications administered during surgery can trigger allergic reactions. Therefore, it is critical that all known allergies are listed clearly.

Another common mistake involves not circling the correct option for anesthesia type. This choice can impact patient comfort and safety during the procedure. Careful attention should be paid to the given options and the appropriate selection made.

Patients may also overlook details about their medical history. In particular, it’s vital to disclose past medical issues that could affect the surgery. This could include anything from previous surgeries to ongoing health concerns. Omitting this information can lead to complications.

Furthermore, people sometimes forget to include the surgeon’s name or referring physician. This detail is essential for coordination and will facilitate communication among healthcare providers. An incomplete referral could delay treatment or create confusion.

A significant number of people leave the additional orders or special instructions section blank. This space exists to communicate any unique needs or considerations that could improve care. Using this section efficiently can greatly enhance the patient’s experience.

Lastly, failing to check for any spelling errors can also derail the process. Mistakes in names or other critical information can lead to misunderstandings and complications. A quick review of the completed form before submission can save both time and frustration.

Documents used along the form

In healthcare, especially concerning surgical procedures, various documents play a crucial role in ensuring that everything proceeds smoothly. Along with the Surgery Scheduling Sheet, several other forms and documents are often utilized. Each serves a distinct purpose in the pre-operative process, helping facilitate communication between healthcare providers and ensuring patient safety and preparedness.

  • Patient History Form: This document collects comprehensive information about the patient's medical history, including previous surgeries, chronic conditions, allergies, and current medications. It is essential for the medical team to understand the patient's health background to mitigate risks during surgery.
  • Consent Form: The consent form is a legal document that ensures the patient understands the nature of the surgery, its risks, benefits, and alternatives. It is vital that patients provide informed consent before any surgical procedure.
  • Preoperative Assessment Form: This form assesses the patient’s readiness for surgery. It typically includes evaluations of vital signs, laboratory tests, and other necessary screenings to confirm that the patient is healthy enough to undergo the procedure.
  • Anesthesia Evaluation Form: Used to gather details about a patient’s health related specifically to anesthesia administration, this form helps anesthesiologists determine the safest method of sedation for the individual patient.
  • Insurance Verification Form: This form verifies that the patient's insurance coverage is valid for the surgery. The process often involves confirming the policy details and any pre-authorization requirements.
  • Postoperative Instructions: After surgery, patients receive this document outlining care guidelines. It includes information on wound care, pain management, symptoms to watch for, and follow-up appointment details.
  • Referral Form: If surgery requires a specialist, a referral form may be necessary. This document includes the referring physician's information and details about the patient’s condition, ensuring continuity of care.

These documents must be accurately completed and communicated among all parties involved in the surgical process. Each plays a pivotal role in enhancing patient safety and streamlining surgical operations, ultimately contributing to a successful surgical experience.

Similar forms

  • Pre-Operative Assessment Form: Similar to the Surgery Scheduling Sheet, this document gathers essential information about a patient's medical history, allergies, and current medications. Both forms aim to ensure the patient's safety during surgery.
  • Patient Information Form: This form collects personal and demographic details of the patient. Like the Surgery Scheduling Sheet, it emphasizes the importance of accurate information for effective care.
  • Insurance Verification Form: This document is used to confirm a patient's insurance coverage. Similar to the Surgery Scheduling Sheet, it requires copying the insurance card to facilitate billing and payment processes.
  • Consent for Surgery Form: This form ensures that the patient understands the procedure and its risks. Both documents prioritize patient awareness and consent before surgical intervention.
  • Admission Form: The Admission Form gathers necessary details when a patient arrives at a healthcare facility. Similar to the Surgery Scheduling Sheet, it helps streamline the check-in process for patients undergoing surgery.
  • Post-Operative Instructions: This documentation provides guidance on care after the surgery. It relates closely to the Surgery Scheduling Sheet, as both emphasize comprehensive care before and after surgical procedures.
  • Anesthesia Consent Form: This form collects patient agreement for anesthesia administration during surgery. Like the Surgery Scheduling Sheet, it requires clear communication regarding safety and procedure details.
  • Medication List Form: This document allows patients to record their medications. It is similar to the Surgery Scheduling Sheet in that both documents focus on essential details that impact surgical outcomes.

Dos and Don'ts

When filling out the Surgery Scheduling Sheet form, it is essential to follow certain guidelines to ensure a smooth process. Here’s a helpful list of things you should and shouldn't do:

  • Do: Enter your information clearly and legibly to avoid any miscommunication.
  • Do: Double-check that you have filled in all required fields, including your surgery date, arrival time, and personal details.
  • Do: Include copies of your insurance card, as this is necessary for billing and verification purposes.
  • Do: Communicate any allergies or medical conditions, as this information is critical for your safety.
  • Don't: Leave out important information. Ensure all sections are complete to prevent delays.
  • Don't: Submit the form without your physician’s signature; it is required for processing your surgery.

By adhering to these dos and don’ts, you can help facilitate your surgery scheduling process and ensure that you’re effectively prepared for your upcoming procedure.

Misconceptions

Misconception 1: The Surgery Scheduling Sheet is only for inpatient procedures.

Many believe that this form is exclusive to inpatient surgeries. However, it also includes options for outpatient and observation procedures, making it applicable to a wider range of surgical settings.

Misconception 2: Completing the form is unnecessary if all information has been communicated verbally.

While verbal communication is important, the Surgery Scheduling Sheet serves as a formal record. This ensures that all details are documented accurately and can be referenced by staff as needed.

Misconception 3: It's sufficient to provide a copy of the insurance card without completing the scheduling sheet.

A copy of the insurance card is required, but it must accompany the completed Surgery Scheduling Sheet. Both are essential for processing and scheduling the surgery smoothly.

Misconception 4: The Surgery Scheduling Sheet does not require a physician's signature.

A physician’s signature is a key requirement on the form. It indicates that the physician has approved the procedure and understands the patient's current condition.

Misconception 5: Patients can arrive at any time on the day of surgery without prior scheduling confirmation.

Patients must arrive at the designated time specified on the Surgery Scheduling Sheet. Arriving promptly allows adequate time for pre-surgery protocols and ensures a smooth experience.

Misconception 6: The form does not require any special instructions or notes.

While it may seem optional, patients are encouraged to include any additional orders or special instructions on the form. This information can be vital for ensuring tailored care on the day of the surgery.

Misconception 7: Only one contact number is needed on the form.

Multiple contact numbers are requested to ensure the medical team can reach the patient or their guardians easily. Providing home, work, and cell phone numbers can facilitate better communication.

Misconception 8: The Surgery Scheduling Sheet is only relevant for patients undergoing surgeries with complications.

This form is important for all patients, regardless of their health history. It is designed to collect necessary information to provide consistent care and ensure safety for every type of surgery.

Key takeaways

Using the Surgery Scheduling Sheet effectively ensures a smoother process for both the patient and medical staff. Here are some key takeaways to consider:

  • Fill Out Completely: Ensure all sections of the form are filled out accurately, including patient details, surgery date, and physician information. Incomplete forms can lead to delays.
  • Confirm Pre-Surgery Instructions: Make sure to follow pre-surgery instructions carefully. This includes medication protocols and fasting times.
  • Bring Necessary Documentation: Patients should always carry their insurance card, any previous test results, and a list of medications during the visit.
  • Arrangements After Surgery: It’s crucial to arrange for someone to drive the patient home. Patients will not be able to drive themselves.

Following these guidelines helps ensure a positive experience during what can be a stressful time for many. Preparation and communication can significantly enhance the surgical journey.